Complicaciones en posoperatorio inmediato de cirugía uretral anterior; ¿existe relación con la recaída? / Early complications in urethral anterior surgery; is there any relationship with recurrence?

INTRODUCCIÓN/OBJETIVO: La estrechez uretral puede causar síntomas miccionales, dolor, disfunción vesical y eyaculatoria. La tasa de complicaciones en uretroplastía anterior es baja. El principal objetivo es evaluar complicaciones del posoperatorio (pop) inmediato (dentro de los 30 días pop). El objetivo secundario es valorar la relación entre complicaciones y la tasa de recaída. MATERIALES Y MÉTODO: Se realizó una revisión retrospectiva de las uretroplastías anteriores realizadas entre octubre del 2012 y junio del 2017. Se valoró: reinternación, reingreso a cirugía, infarto agudo de miocardio, tromboembolismo de pulmón, trombosis venosa profunda, óbito, infecciones, dehiscencia de herida, hematomas, sangrados, etc. Se definió recaída a la necesidad de realizar cualquier instrumentación uretral secundaria a la uretroplastía. Las variables se analizaron estadísticamente con Chi square y Mann-Whitney U test. RESULTADOS: Se incluyeron 92 pacientes, con un seguimiento mínimo de 12 meses. Las edades fueron de 18 a 88 años (mediana, 61,5 años). En 58 pacientes, se utilizaron transferencia de tejidos (27 injertos y 31 colgajos). La longitud de la estrechez fue desde 1-15 cm (media, 3,25 cm). La iatrogénica (56%) fue la etiología más frecuente. 56 pacientes (63%) tenían tratamientos previos. La tasa de complicaciones pop inmediato fue del 32%, las infecciones fueron las más frecuentes. Según Clavien, se clasificaron: I: 40%; II: 47%; III: 10%; IV: 3%. Hubo 17 recaídas (18%), 13 dentro de los primeros 6 meses del pop. De los pacientes que presentaron complicaciones, recayó el 23%; solo 16% de los que no las presentaron (p: 0,4). Aquellos pacientes con complicaciones graves presentaron mayor tasa de recaída (p: 0,2). CONCLUSIÓN: La tasa de complicaciones pop inmediata de uretroplastía anterior fue de 32%; las infecciones fueron las más frecuentes. La mayoría fue Clavien I y II. La recaída fue mayor en aquellos pacientes que sufrieron complicaciones en pop inmediato.

INTRODUCCION/OBJECTIVE: Urethral stenosis can cause mictional symptoms, pain, bladder dysfunction and ejaculatory problems. Complications rate in anterior urethroplasty is low. Main objetive is to evaluate early post operatory complications Secondary objetive is to assess the relationship between complications and recurrence rate. MATERIALS AND METHODS: We performed a restrospective review of our anterior urethroplasty database between October 2012 and June 2017. We recorded: patients readmission, return to operating room, acute myocardial infarction, pulmonary embolism, deep venous thrombosis, death, infections, wound dehiscense, hematomas, bleedings, etc. We defined recurrence as any urethral instrumentation after urethroplasty. Variables were analyzed using Chi Square and Mann Whitney U test. RESULTS: 92 patients were included in the study with at least 12 months follow up. Age range was between 18-88 years. (median 61,5 years) Substitution urethroplasty were performed in 58 patients (grafts 27 and flaps 31) Urethral stenosis lenght range was between 1 and 15 cm (mean 3,25cm) Most frequent cause of urethral stenosis was iatrogenic (56%) 56 patients underwent previous treatment (63%) Complication rate in early post operative period was 32%, most of them infections. Clavien clasiffication: I: 40%; II: 47%; III: 10%; IV: 3%. There were 17 recurrences (18%), 13 during the first 6 months after surgery. 23 % of patients with complications had recurrence and only 16% of patients without, had recurrence (p:0,4) Patients with serious complications had greater recurrence rate (p: 0,2) CONCLUSION: Recurrence rate in early complications of anterior urethroplasty was 32%, most of them infections. Clavien I and II are the most frequent. Recurrence was greater in patients who suffered early complications

Assessment of long term outcomes after buccal mucosal graft urethroplasty: the impact of chronic kidney disease

ABSTRACT Objectives To compare and assess various outcomes and success of buccal mucosal graft urethroplasty (BMGU) in patients with CKD versus patients having normal renal function. Material and Methods This was a retrospective, single centre study, during period 2013 to 2017. Patients were grouped into two groups. Group 1 had patients with estimated Glomerular Filtration Rate (eGFR)>60mL/min/1.73m2 while group 2 had patients with eGFR <60mL/min/1.73m2. eGFR was calculated according to the MDRD equation. The two groups were compared with regard to various outcomes like length, location of stricture, technique of graft placement, intra-operative blood loss (haemoglobin drop), duration of hospital stay, post-operative complications and recurrence. Results A total of 223 patients were included in study with group 1 had 130 patients and group 2 had 93 patients. Mean age of patients with CKD were higher (47.49 years versus 29.13 years). The mean follow-up period was comparable between both groups (23.29 months and 22.54 months respectively). Patients with CKD had more post-operative Clavien Grade 2 or higher complications (p=0.01) and a greater recurrence rates (p<0.001) than in non-CKD patients. On multivariate analysis, age and CKD status was significant predictor of urethroplasty success (p=0.004) (OR= 14.98 (1.952-114.94, 95% CI). Conclusions CKD patients are more prone to post-operative complications in terms of wound infection, graft uptake and graft failure and higher recurrence rates following BMGU.

Bilateral compartment syndrome of the lower limbs after urological surgery in the lithotomy position: a clinical case / Síndrome compartimental dos membros inferiores após cirurgia urológica na posição de litotomia: um relato de caso

Acute compartment syndrome of the lower extremities after urological surgery in the lithotomy position is a rare but potentially devastating clinical and medicolegal problem. We report the case of a 67-year-old male who underwent laparoscopic prostatectomy surgery to treat cancer, spending 180 minutes in surgery. Postoperatively, the patient developed acute compartment syndrome of both legs, needing emergency bilateral four-compartment fasciotomies, with repeated returns to the operating room for second-look procedures. The patient also exhibited delayed wound closure. He regained full function within 6 months, returning to unimpaired baseline activity levels. This report aims to highlight the importance of preoperative awareness of this severe complication which, in conjunction with early recognition and immediate surgical management, may mitigate long-term adverse sequelae and improve postoperative outcomes

A síndrome compartimental aguda dos membros inferiores após cirurgia urológica na posição de litotomia é um problema clínico e médico-legal raro, mas potencialmente devastador. Reportamos o caso de um homem de 67 anos submetido a uma prostatectomia laparoscópica por câncer. A cirurgia durou 180 min. No pós-operatório, o paciente desenvolveu síndrome compartimental aguda de ambos os membros inferiores, necessitando de fasciotomias de urgência, com retornos repetidos à sala de cirurgia para procedimentos adicionais. O paciente também apresentou fechamento tardio da ferida. Ele recuperou a função completa dentro de 6 meses e retornou a um nível de atividade basal irrestrito. Este artigo tem a importância de ressaltar a consciência pré-operatória desta grave complicação que, em conjunto com o reconhecimento precoce e o tratamento cirúrgico imediato, pode mitigar sequelas adversas em longo prazo e melhorar os resultados pós-operatórios

Costs analysis of surgical treatment of stress urinary incontinence in a brazilian public hospital, comparing Burch and synthetic sling techniques

ABSTRACT Introduction Surgical treatment of urinary incontinence progressed significantly with the introduction of synthetic slings. However, in some public Brazilian hospitals, the costs of these materials prevent their routine use. Objective To compare the costs of ambulatory synthetic sling surgery with an historical series of patients submitted to Burch surgery in a Brazilian public hospital. Materials and Methods Twenty nine incontinent patients were selected to synthetic sling surgery. Demographic data were prospectively collected and also the costs of the procedure, including drugs and materials, use of surgical and recovery wards, medical staff and hospitalization. These data were compared to the costs of 29 Burch surgeries performed before the introduction of synthetic slings. Results Demographic data were similar, although median age was lower in the group submitted to Burch surgery (46.3±8.6 versus 56.2±11.3 (p<0.001)). Cost was significantly lower in patients submitted to sling in all items, except for time spent in recovery ward. Total value of 29 Burch surgeries was R$ 217.766.12, and of R$ 68.049.92 of 29 patients submitted to sling surgery (p<0.001). Conclusion Burch surgery was more expensive than ambulatory synthetic transobturator sling surgery, even when the cost of the synthetic sling was considered.

Perineostomy: the last oportunity

Objective To review the technique and outcome of perineal urethrostomy or urethral perineostomy and to identify factors related to the procedure failure. Material and methods We studied 17 patients who underwent perineal urethrostomy between 2009-2013 in a single hospital. Success was defined as no need for additional surgical treatment or urethral dilatation. We reviewed the clinical data related to age, weight, previous urethral surgery, diabetes, hypertension, ischemic cardiopathy, lichen sclerosus and other causes and studied their association with the procedure failure (univariate analysis). We completed the analysis with a multivariate test based on binary regression. Results The average follow-up was 39.41 months. From all the causes, we found Lichen Sclerosus in 35%, idiopathic etiology in 29% and prior hypospadia repair in 18%. Postoperative failure occurred in 3 patients, with a final success of 82.4%. The binary regression model showed as independent risk factors ischemic cardiopathy (OR: 2.34), and the presence of Lichen Sclerosis (OR: 3.21). Conclusions The success rate with the perineal urethrostomy technique shows it to be a valid option above all when we preserve the urethral blood supply and plate. Lichen sclerosus and ischemic vascular problems are risk factors to re-stenosis. .

Complicaciones postoperatorias de la cistouretropexia con cinta transobturatriz (TOT) en pacientes con y sin cirugía concomitante atendidas en el Hospital Nacional Arzobispo Loayza durante el periodo 2008 al 2011 / Postoperative complications of the transobturator tape cystourethropexy (TOT) in patients with and without concomitant surgery treated at the National Hospital Arzobispo Loayza during the period 2008 to 2011

OBJETIVO: Determinar las complicaciones postoperatorias de la Cistouretropexia con cinta transobturatriz en pacientes con y sin cirugía concomitante, atendidos en el Hospital Nacional Arzobispo Loayza durante el periodo 2008 - 2011. METODOLOGIA: Estudio observacional, analítico-comparativo, retrospectivo de corte transversal, realizado en 220 pacientes con incontinencia urinaria de esfuerzo programadas para cistouretropexia con cinta transobturatriz con y sin otra cirugía concomitante, en el Hospital Nacional Arzobispo Loayza durante el periodo 2008 - 2011, RESULTADOS: Se encontró en general una edad promedio de 60.3±11.9 años, mientras que para aquellas intervenidas con alguna cirugía concomitante el promedio de edad fue de 56,1±11,2 años y 62.0±11,7 años para aquellas intervenidas sin cirugía concomitante alguna. La mayoría fueron de estado civil casadas (50 por ciento), de grado de instrucción educación primaria (44.5 por ciento) y de ocupación ama de casa (94.5 por ciento). El 64.5 por ciento de ellas tuvieron al menos sobrepeso (IMC>25kg/m2). Tanto el grupo control como el grupo comparativo tuvieron características similares en cuanto a edad (p=0.358), grado de instrucción (p=0.155) e IMC (p=0.759). Respecto a los antecedentes clínicos de importante, la mayoría tuvo como antecedente la multiparidad, tanto en aquellas con cirugías concomitantes (89.2 por ciento) y sin cirugías concomitantes (87.1 por ciento) (p=0.896). Asimismo, la mayoría solo tuvo partos de tipo vaginal, 84.6 por ciento para aquellas intervenidas con cirugía concomitante y 94.8 por ciento para aquellas intervenidas sin cirugía concomitante alguna (p=0.01). Además la mayoría de pacientes manifestó encontrarse en edad post menopaúsica, 78.5 por ciento en aquellas intervenidas con alguna cirugía concomitante manifestaron y 89.7 por ciento en quienes no se realizó cirugía concomitante alguna (p=0.027). En cuanto a los antecedentes quirúrgicos, casi el 90 por ciento mencionó no haber sido...

Cirugía urológica en pacientes de 80 años y más: ¿es la edad un factor de riesgo para el desarrollo de complicaciones postoperatorias? / Urological surgery in patients 80 years and older: is age a risk factor for the development of postoperative complications?

La expectativa de vida ha ido aumentando en Chile y en el mundo, lo que ha causado un gran impacto a nivel del número de cirugías que se realiza en la población añosa. El objetivo de este trabajo es describir la experiencia de nuestro centro en cirugías urológicas en pacientes mayores de 80 años y analizar que factores aumentan el riesgo de complicaciones postquirúrgicas.Materiales y método: Análisis retrospectivo de 138 cirugías urológicas realizadas en 120 pacientes mayores de 80 años, durante los años 2000 a 2012. Se obtuvo información sociodemográfica, riesgo quirúrgico (ASA), tipo y duración de cirugía realizada, complicaciones post-operatorias (escala de Clavien) y tiempo de hospitalización. Los datos obtenidos fueron analizados mediante el programa SPSS v17. Se realizó análisis multivariado y se estableció el riesgo relativo para el desarrollo de complicaciones. Se consideró signi ficativo p<0,05. Resultado: La edad promedio de los pacientes fue de 84+/-3.7 años, 86.2 por ciento fueron hombres. El 96.7 por ciento presentaba algún tipo de comorbilidad, con predominio de hipertensión arterial (60,84 por ciento) y diabetes mellitus tipo 2 (24,16 por ciento). La mayoría de las intervenciones fue de complejidad intermedia (77.27 por ciento), donde la anestesia regional (56,8 por ciento) y la vía endo urológica (84,78 por ciento) fueron las más utilizadas, con un tiempo operatorio promedio de 62+/-52.4 minutos. El riesgo quirúrgico prevalente fue ASA2 (62.7 por ciento). El promedio de hospitalización fue de 2,8+/-2.7 días. El 15.21 por ciento de los pacientes presentó algún tipo de complicación, con predominio de clasifi cación tipo 1 de Clavien (38 por ciento). En el análisis multivariado se evidenció como factores de riesgo signi ficativos para complicaciones, edad mayor a 90 años (p=0.03), presencia de insu ciencia renal (p=0.01), portar 4 o más comorbilidades (p=0.04), cirugía mayor a 3 horas (p=0.03) y tener riesgo quirúrgico ASA3 (p=0.04)...

Life expectancy has been increasing in Chile and in the World. This has caused a great impact over the number of surgeries being performed in the elderly population. The aim of this paper is to describe the experience of our center in urological surgery in patients older than 80 years and analyze which factors increase the risk of postoperative complications.Materials and methods: Retrospective analysis of 138 urological surgeries performed in 120 patients older than 80 years, during the years 2000-2012. Sociodemographic information, surgical risk (ASA), type and duration of surgery, postoperative complications (Clavien scale) and length of hospitalization was obtained. The data were analyzed using SPSS v17. Multivariate analysis was performed and the relative risk for developing complications was established. Signi cance was p <0.05. Average age of the patients was 84 +/- 3.7 years, 86.2percentwere men. The 96.7 percenct had some kind of comorbidity, with prevalence of hypertension (60.84 percent) and diabetes mellitus type 2 (24.16 percent). Most of the interventions was of intermediate complexity (77.27percent), where regional anesthesia (56.8 percent) and endourological aproach (84.78 percent) were the most used, with average operative time of 62 +/- 52.4 minutes. Most common Surgical risk was ASA2 (62.7 percent). Average hospital stay was 2.8 +/- 2.7 days. 15.21 percent of patients had some type of complication, with a predominance of type 1 Clavien classication (38 percent). The multivariate analysis showed signi cant risk factors for complications: age greater than 90 years (p = 0.03), renal failure (p = 0.01), carrying 4 or more comorbidities (p = 0.04), surgery Langer than 3 hours (p = 0.03) and ASA3 surgical risk (p =.04). No mortality was reported in our series. In this study, although most of our patients underwent endourological procedures, we evidence that surgery in patients older than 80 years is feasible...

Initial experience of a novel ergonomic surgical chair for laparoscopic pelvic surgery

INTRODUCTION: We present the initial experience of a novel surgical chair for laparoscopic pelvic surgery, the ETHOS TM (Bridge City Surgical, Portland, OR). MATERIALS AND METHODS: The ETHOS chair has an adjustable saddle height that ranges from 0.89 to 1.22 m high, an overall width of 0.89 m, and a depth of 0.97 m. The open straddle is 0.53 m and fits most OR tables. We performed 7 pelvic laparoscopy cases with the 1st generation ETHOS TM platform including 2 laparoscopic ureteral reimplantations, 5 laparoscopic pelvic lymphadenectomies for staging prostate cancer in which one case involved a laparoscopic radical retropubic prostatectomy, performed by 2 different surgeons. RESULTS: All 7 pelvic laparoscopic procedures were successful with the ETHOS TM chair. No conversion to open surgery was necessary. Survey done by surgeons after the procedures revealed minimal stress on back or upper extremities by the surgeons from these operations even when surgery was longer than 120 minutes. Conversely, the surgical assistants still had issues with their positions since they were on either sides of the patient stressing their positions during the procedure. CONCLUSION:The ETHOS chair system allows the surgeon to operate seated in comfortable position with ergonomic chest, arms, and back supports. These supports minimize surgeon fatigue and discomfort during pelvic laparoscopic procedures even when these procedures are longer than 120 minutes without consequence to the patient safety or detrimental effects to the surgical team.

Manejo percutáneo de tumores de células transicionales de la pelvis renal: serie de casos y revisión de la literatura / Percutaneous treatment of renal pelvis transitional cell tumors: case series and review of the literature

Introducción: El carcinoma de células transicionales de la vía urinaria superior es una condición poco frecuente. Poseen un alto porcentaje de recidivas y las alternativas terapéuticas son numerosas. El gold standard terapéutico es la nefroureterectomía radical. Ésta se asocia a una mayor incidencia de insuficiencia renal y muerte por condiciones relacionadas a ésta. Actualmente se encuentran en desarrollo varias terapias con preservación renal, técnicas mínimamente invasivas entre las cuales las principales son la resección por vía percutánea y la resección endoscópica por ureter o nefros copia. Material y método: presentamos una serie de casos de cuatro pacientes portadores de CCT-VUS sometidos a tratamiento percutáneo. Resultados: el tamaño tumoral promedio fue de 14,5 mm (8–20 mm), tres de ellos presentaron lesiones no invasoras y uno de ellos una lesión invasora. No hubo mayores complicaciones, el sangrado promedio fue de 225 cc, ningún paciente requirió de transfusiones de hemoderivados y la estadía hospitalaria de 3,75 días en promedio. Sólo uno de los paciente requirió de tratamiento complementario (tumor invasor), siendo sometido a una nefroureterectomía radical laparoscópica. Actualmente todos los pacientes se encuentran en remisión completa con un tiempo de seguimiento promedio de 50,25 meses (34-61). Conclusiones: el tratamiento percutaneo de los CCT-VUS es una alternativa válida, asociada a una baja taza de complicaciones y segura desde el punto de vista oncológico.

Introduction: Transitional cell carcinoma of the upper urinary tract is an uncommon disease. They have a high percentage of recurrences and the therapeutic approaches are numerous. The treatment gold standard is radical nephrouretherectomy. This is associated with a higher incidence of chronic renal failure y dead from associated conditions. Actually, various nephron sparring therapies are in development. The main techniques are the percutaneous resection and the ureteroscopic resection. Matherials and methods: we present a case series of four patients diagnosed with transitional cell carcinoma of the upper urinary tract treated by a percutaneous approach. Results: mean tumor size was 14.5 mm (8–20 mm), three of them had superficial tumors and one of them invasive ones. There was no mayor complications, average bleeding was 225 cc, no patient needed blood transfusions and mean hospitalization time was 3.75 days. Only one patient required complementary treatment (patient with invasive tumor), being treated with laparoscopic radical nephrouretherectomy. Actually all patients are at complete response to treatment, with an average follow up time of 50.25 months (34-61).Conclusions: percutaneous approach for transitional cell carcinoma of the upper urinary tract is a valid treatment option, associated with a low complications rate and safe form an oncological view. Key words: transitional cell carcinoma of the upper urinary tract, percutaneous surgery, chronic renal failure.

Complications rates of non-oncologic urologic procedures in population-based data: a comparison to published series

PUSPOSE: Published single institutional case series are often performed by one or more surgeons with considerable expertise in specific procedures. The reported incidence of complications in these series may not accurately reflect community-based practice. We sought to compare complication and mortality rates following urologic procedures derived from population-based data to those of published single-institutional case series. MATERIALS AND METHODS: In-hospital mortality and complications of common urologic procedures (percutaneous nephrostomy, ureteropelvic junction obstruction repair, ureteroneocystostomy, urethral repair, artificial urethral sphincter implantation, urethral suspension, transurethral resection of the prostate, and penile prosthesis implantation) reported in the U.S.’s National Inpatient Sample of the Healthcare Cost and Utilization Project were identified. Rates were then compared to those of published single-institution series using statistical analysis. RESULTS: For 7 of the 8 procedures examined, there was no significant difference in rates of complication or mortality between published studies and our population-based data. However, for percutaneous nephrostomy, two published single-center series had significantly lower mortality rates (p < 0.001). The overall rate of complications in the population-based data was higher than published single or select multi-institutional data for percutaneous nephrostomy performed for urinary obstruction (p < 0.001). CONCLUSIONS: If one assumes that administrative data does not suffer from under reporting of complications then for some common urological procedures, complication rates between population-based data and published case series seem comparable. Endorsement of mandatory collection of clinical outcomes is likely the best way to appropriately counsel patients about the risks of these common urologic procedures.

Laparoscopic ureteral reimplant for ureteral stricture

Purpose: Evaluate the initial experience of laparoscopic ureteral reimplant for ureteral stenosis. Materials and methods: From January 2004 to June 2008, 10 patients underwent 11 laparoscopic reconstruction surgeries for ureteral stenosis. Seven cases of stenosis of the distal ureter, two at the level of iliac vessels, a case of bilateral distal stenosis and one in the medium third. Eight ureteroneocystotomies were performed by extravesical technique with anti-reflux mechanism, two cases of vesical reimplant with Boari technique and one case using the psoas hitch technique. Results: The average surgical time was 166 minutes (115-245 min), mean blood loss was 162 mL (100-210 mL) and the average hospital stay was 2.9 days (2-4 days). There were two complications: a lesion of the sigmoid colon identified peroperatively and treated with laparoscopic sutures with good evolution, and a case of ureteral stone obstruction at the 30th day postoperative, treated by laser ureterolitotripsy. All patients had resolution of the stenosis at an average follow-up period of 18 months (3-54 months). Conclusions: Laparoscopic surgery represents a feasible, safe and low morbidity technique for ureteral reimplant in ureteral stenosis.

Cinta suburetral transobturatriz libre de tensión para el tratamiento de la incontinencia de orina de esfuerzo: 3 años de seguimiento / Tension-free subureteral tape for stress urinary incontinence

Objetivos: Evaluar nuestros resultados en la corrección de la incontinencia de orina de esfuerzo (IOE) con una técnica de cinta suburetral transobturatriz modificada (TOTm) con malla desnuda de polipropileno y anestesia local, midiendo efectividad, calidad de vida y grado de satisfacción por 3 años de seguimiento. Método: Evaluación prospectiva de 56 pacientes operadas entre los años 2003 y 2005, con IOE moderada o severa, según diagnóstico por clínica y cistometría simple. Se logró realizar un seguimiento del 87 por ciento de las pacientes, por 37,9 meses (19-51 meses). Se realizó control con examen físico y se aplicó una encuesta de satisfacción en visita domiciliaria por un grupo independiente de encuestadores. Resultados: Un 88 por ciento de las pacientes se encuentra sin IOE en el examen físico. A la encuesta de satisfacción, las pacientes manifestaron sentirse mejor o mucho mejor en frecuencia miccional diurna (79 por ciento), disfunción del vaciamiento vesical (69 por ciento), dolor pelviano (58 por ciento), urgeincontinencia (84 por ciento) y función sexual (53 por ciento). Un 90 por ciento manifiesta sentirse mejor o mucho mejor de la IOE que antes de la operación. La urgencia o urgeincontinencia de novo apareció en un 6 por ciento. Conclusiones: La técnica TOTm utilizada por nuestro grupo tiene resultados comparables con las técnicas TOT originales, con mejoría significativa en la calidad de vida de las pacientes.

Objective: To review our results in the correction of stress urinary incontinence (SUI) with a modified TOT technique using polypropylene mesh and local anesthesia, measuring effectiveness, quality of life and degree of satisfaction during 3 years of follow-up. Method: Prospective evaluation of 56 patients operated between 2003 and 2005, with modérate or severe SUI, or mixed urinary incontinence with effort predominance, according to clinical diagnosis and simple cystometry. A follow-up of 87 percent of the patients over a period of 37.9 months (19-51 months) was achieved. A physical examination was realized and a survey of satisfaction was applied by a team of independent interviewers on home visits. Results: On physical examination, 88 percent of patients are without SUI. In the survey of satisfaction, the patients manifested feeling better or much better in terms of daytime voiding frequency (79 percent), voiding dysfunction (69 percent), groin pain (58 percent), urge incontinence (84 percent) and sexual function (53 percent); 90 percent manifested feeling better or much better about their SUI than before the operation. De novo urgency or urge incontinence appeared in 6 percent. Conclusions: The modified TOT technique used by our group obtains results that are comparable to those of the original TOT techniques, with a significant improvement in the quality of life of patients.

Cistite glandular evoluindo com uropatia obstrutiva / Cystitis glandularis evolving with obstructive uropathy

Introdução: Cistite glandular é um processo proliferativo benigno e infrequente da mucosa vesical, caracterizado por proliferação do epitélio e, em alguns casos, formação de glândulas intestinais. Alterações metaplásticas na cistite glandular são bem documentadas na literatura, embora sua etiologia não seja totalmente esclarecida. Relato do caso: Relatamos um caso de cistite glandular em um paciente de 55 anos, apresentando sintomas miccionais irritativos e obstrutivos persistentes sem resposta à terapia com alfabloqueadores. Ultrassonografia evidenciou lesão vegetante no trígono vesical e o paciente foi submetido à ressecção endoscópica por duas vezes e evoluiu com ureterohidronefrose bilateral. Dado o extenso acometimento vesical e a persistência dos sintomas, o paciente foi submetido a cistoprostatectomia e neobexiga ileal com boa evolução pós-operatória. Discussão: Há duas formas de cistite glandular: típica e intestinal. A forma típica é a mais comum e a intestinal é marcada pela produção de mucina, mais frequentemente associada ao adenocarcinoma de bexiga. A maioria dos casos de cistite glandular é assintomática, sendo que os pacientes sitomáticos normalmente apresentam hematúria, sintomas urinários irritativos e típicos de cistite crônica. Há controvérsias sobre o tratamento precoce agressivo, sendo que vários estudos propõem a ressecção transuretral e o acompanhamento com biópsias.

Introduction: glandular cystitis is a benign proliferative process and infrequent mucosal bladder, characterized by proliferation of the epithelium and in some cases, formation of intestinal glands. Metaplásticas changes in glandular cystitis are well documented in the literature, although its etiology is not fully understood. Case report: A case of glandular cystitis in one patient of 55 years, with irritative and obstructive urinary symptoms persisted without response to therapy with alpha blockers. Ultrasonography revealed a vegetative lesion in the trigonal and the patient underwent endoscopic resection and twice progressed to bilateral ureterohidronefrose. Given the extensive bladder involvement and persistence of symptoms, the patient underwent ileal neobladder cistoprostatectomia and with good postoperative evolution. Discussion: There are two types of glandular cystitis: typical and intestinal tract. The typical form is the most common and is characterized by intestinal mucin production, most often associated with adenocarcinoma of the bladder. Most cases of glandular cystitis is asymptomatic, and patients usually present sitomáticos hematuria, urinary symptoms and typical of chronic cystitis. There is controversy over early aggressive treatment, and several studies suggest transurethral resection and follow-up biopsies.

Contribuições à técnica cirúrgica em transplante renal: Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo / Contributions to the surgical tecniques of kidney transplantation: Clinic Hospital of São Paulo University School of Medicine

Não é infreqüente ouvir que, em transplante renal, inovações de impacto no âmbito cirúrgico já não são mais prováveis. No entanto, soluções de alto impacto econômico ainda surgem com freqüência e muitas delas têm surgido no Brasil, contribuindo significativamente para a mudança de conduta cirúrgica em transplante renal a nível mundial. A técnica cirúrgica do transplante renal propriamente dita está bem estabelecida há anos, sendo muito parecida entre os diversos serviços de transplante. Já no que se refere ao tratamento cirúrgico das complicações do transplante e dos pacientes com doenças associadas à insuficiência renal crônica dialítica (IRCD), observamos considerável controvérsia e variação nas condutas. Este estudo pretende oferecer um panorama sobre as técnicas cirúrgicas utilizadas no transplante renal, as complicações decorrentes deste procedimento e os resultados obtidos pelo Serviço de Transplante Renal do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo...

Is not rare to hear that, on kidney transplantation, improvements on surgical aspects are not probable anymore. Although, solutions with high economical impact arises frequently and, many of them, in Brazil, contributing, significantly, for changes on surgical conduct on kidney transplantation worldwide. The surgical techniques for kidney transplantation are well established and do not change between the groups of transplants. Although, the surgical treatment of complicated outcomes and of patients with diseases related to chronic renal failure is still controversial. This study aims to offer a general overview about the surgical techniques of kidney transplantation, complications inherent to this procedure and the results obtained by the Kidney Transplantation Team of Clinic Hospital of São Paulo University Medical School.

Clinical and quality-of-life outcomes after autologous fascial sling and tension-free vaginal tape: a prospective randomized trial

Purpose: Evaluate the impact autologous fascial sling (AFS) and tension-free vaginal tape (TVT) procedures on quality-of-life in incontinent women. Materials and Methods: Forty-one women were randomly distributed into two groups. Group G1 (n = 21), underwent AFS and group G2 (n = 20) TVT implant. The clinical follow up was performed at 1, 6, 12 and 36 months. Results: TVT operative time was significantly shorter than AFS. Cure rates were 71 percent at 1 month, 57 percent at 6 and 12 months in G1. In G2, cure rates were 75 percent at 1 month, 70 percent at 6 months and 65 percent at 12 months; there was no significant difference between groups. As regards the satisfaction rate, there was no statistical difference between groups. Analysis of quality of life at 36 months revealed that there was no significant difference between groups. Conclusion: Similar results between AFS and TVT, except for operative time were shorter in TVT.

Does vaginal anti-incontinence surgery affect sexual satisfaction? A comparison of TVT and Burch-colposuspension

OBJECTIVE: To evaluate the sexual satisfaction rates of women who underwent tension-free vaginal tape (TVT) procedure for stress urinary incontinence and compare it with the results of Burch-colposuspension. MATERIALS AND METHODS: A self-administered questionnaire was given to 81 patients who had undergone TVT or Burch-colposuspension at our institution to determine sexual satisfaction rates and reasons for dissatisfaction. Forty-seven patients in TVT group and 22 patients in Burch-colposuspension group were considered eligible for the study. The mean follow-up period and age of patients in TVT and Burch-colposuspension groups were 34 months, 51.5 years and 89 months, 52.9 years, respectively. The difference between the ages in the two groups was not statistically significant, while the difference between mean follow-up periods was significant (p = 0.000). RESULTS: When evaluating sexual satisfaction, 73 percent in the TVT group and 86 percent in the Burch-colposuspension group did not report any difference in sexual satisfaction following surgery, while in the TVT group, 23 percent expressed negative and 4 percent positive changes, and in the Burch-colposuspension group 9 percent expressed negative and 5 percent positive post surgical changes. The differences in sexual satisfaction rates between the two groups were not considered significant. The majority (54 percent) of those who expressed a negative change suffered from dyspareunia. CONCLUSIONS: Although sexual satisfaction seems to be more adversely affected by TVT compared to Burch-colposuspension, the difference was not statistically significant. Further studies are required concerning different anti-incontinence techniques in order to arrive at more precise conclusions.

Experiencia en el tratamiento endoscópico de la litiasis ureteral / Experience in the endoscopic treatment of ureteral stones

Objetivos: La endourología con procedimientos menos invasivos ha sustituido la cirugía convencional en el manejo de algunas patologías, con una baja morbilidad y altos índices de resolución. El progreso de la ureteroscopia con disminución del calibre del instrumental y mejoría de los sistemas ópticos y accesorios han permitido mejor acceso y visión del tracto urinario, disminuyendo los índices de complicaciones. Material y Método: análisis retrospectivo de nuestra experiencia en el abordaje ureteroscópico de lalitiasis ureteral durante el período febrero 2004 - diciembre 2005. Se definió el éxito de la cirugía según la fragmentación completa de la litiasis y la desobstrucción respectiva. Resultados: Se realizaron 50 cirugías, distribuidas en rango etareo 18-83 años, 28 pacientes de sexo masculino y 22 de sexo femenino. El tamaño litiásico abordado varió de 0,5 -2 cm. Se logró la fragmentación completa del cálculo en 92 por ciento de los casos, en 2 pacientes se logró fragmentación parcial y en otros 2 no se logró el acceso por migración de la litiasis. Se describen como complicaciones las inherentes al procedimiento, hematuria, perforación ureteral localizada y 1 caso de falsa vía. Conclusiones: La ureterolitotomia endoscópica resulta un procedimiento seguro y eficaz en la resolución de la litiasis ureteral distal con baja morbilidad asociada, la disponibilidad de la litotripsia intracorporea permite mayor flexibilidad en la indicación de esta técnica. Constituye nuestra modalidad de elección, considerando la poca disponibilidad de litotripsia extracorpórea.

Introduction: Endourology has replaced conventional surgery in management of several urological diseases, with a low morbidity and excellent results. The progress of ureteroscopy with reduced and improved instruments and more advanced optical systems have allowed better access and vision of the urinary tract, reducing the rates of complications. Material and Methods: Retrospective analysis of our experience in the ureteroscopic management of ureteral stones during the period from February 2004 - December 2005. Succesful surgery was define We define as successful according to both the fragmentation of the stones and resolution of obstruction. Results: Fifty surgeries were performed in patients with an age range 18-83 years. Male to female ratio was 3/2. Stone tone size ranged from 0.5 to 2 cm. Complete fragmentation was achieved in 92 percent of the cases, 2 patients achieved partial fragmentation and in one case we experienced migration of stone and the procedure was not completed. The complications rate observed I the series was low. Conclusions: Endourological management of ureteral stones is safe and effective for the resolution of distal ureteral calculi with low morbidity. Availability of intracorporeal lithotripsy allows greater flexibility in the indication of this technique. In our hands this woud be the technique of choice.

Sling, tendineovaginal de pericárdio bovino (técnica de Palma): Experiência inicial / Tendineouvaginal sling of bovine pericardium (Palma's technique): initial experience

O autor apresenta os resultados preliminares de um novo "sling", realizado totalmente por via vaginal, sem perfurar a fáscia endopélvica, evitando assim a criaçäo de um efeito paravaginal iatrogênico. Os "slings" aponeuróticos, datam do início do século e embora tenha sido temporariamente abandonada, devido a grande porcentagem de complicaçöes, as mudanças de paradigma que ocorreram, colocaram-na como a mais aceita no tratamento da incontinência urinária por lesäo do mecanismo esfincteriano intrínseco, bem como naqueles casos nos quais há risco de falha das cistouretropexias, tais como em pacientes obesas, com doença pulmonar obstrutiva crônica e falhas de cirurgias anteriores. A obtençäo de aponeurose autóloga exige a realizaçäo de uma grande incisäo abdominal, o que significa dor no pós-operatório, hematomas, infecçöes, e aumento do tempo de permanência hospitalar. Este procedimento é realizado sob anestesia raquídea em posiçäo de litotomia. Injeta-se soro fisiológico na parede vaginal, para facilitar a dissecçäo. Realiza-se incisäo arciforme ao nível do colo vesical, dissecando lateralmente até o ramo ascendente do ísquio. Identifica-se por palpaçäo o colo vesical e o arco tendíneo, no qual säo passados dois fios de propilpropileno 00. Uma faixa de pericárdio bovino estabilizado com glutaraldeído de 2 cm de largura por 6 cm de comprimento é suturada ao colo vesical com pontos absorvíveis. A seguir as extremidades do "sling" säo suturada ao colo vesical com pontos absovíveis. A seguir as extremidades do "sling" säo suturadas ao arco tendíneo, usando os fios previamente passados. Aparede vaginal é fechada com pontos separados de categue 00 cromado. Um cateter de Foley é deixado por 24 horas. Este procedimento restaura o apoio posterior do colo vesical e uretra proximal, permitindo a coaptaçäo uretral sem induzir a retençäo urinária. Trata-se de um procedimento simples, rápido e indolor, que por apresentar 90 por cento de cura e 10 por cento de melhora neste relato inicial, pode ser uma alternativa atraente para casos selecionados de incontinência esfincteriana, caso os bons resultados obtidos sejam duradouros

Paciente quirúrgico con insuficiencia renal crónica / Surgical patient with chronic kidney failure

Se realiza una concisa revisión de los principales aspectos clínicos del paciente con insuficiencia renal crónica en relación con la cirugía y la anestesia, y se recorren tópicos vinculados al riesgo quirúrgico y la farmacología de las drogas anestésicas. Se ofrecen puntos de vista para discutir, entre las tendencias de la práctica especializada actual